Andrew M. Cislo

Continuing Medication and Hospitalization Outcomes After Assisted Outpatient Treatment in New York

OBJECTIVE This study examined whether persons with mental illness who undergo a period of involuntary outpatient commitment continue to receive prescribed medications and avoid psychiatric hospitalization after outpatient commitment ends. METHODS Data on Medicaid pharmacy fills and inpatient treatment were used to describe patterns of medication possession and hospitalization for persons with mental illness after they received assisted outpatient treatment (AOT) in New York between 1999 and 2007 (N=3,576). Multivariable time-series analysis was used to compare post-AOT periods to pre-AOT periods. RESULTS For former AOT recipients, sustained improvements in rates of medication possession and hospitalization in the post-AOT period varied according to the length of time spent in court-ordered treatment. When the court order for AOT was for six months or less, improved medication possession rates and reduced hospitalization were sustained in the post-AOT period only when intensive case coordination services (assertive community treatment, intensive case management, or both) were kept in place. However, when the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services. CONCLUSIONS Benefits of involuntary outpatient commitment, as indicated by improved rates of medication possession and decreased hospitalizations, were more likely to persist after involuntary outpatient commitment ends if it is kept in place longer than six months.

Challenges and solutions for conducting research in correctional settings: The U.S. experience

Through the mid-1970s, most new drug clinical trials were conducted in Americas jails and prisons. Due to the extensive human rights violations acknowledged at that time, laws were enacted that essentially brought corrections-based research to a halt. The Code of Federal Regulations, 45 CFR 46 subpart C, specifies the limitations upon research with correctional populations that are currently in place. These guidelines both informed the ethical conduct of research and arguably created a significant problem in todays correctional environment - prisoners are under-studied. We know far less about the health and health care needs of people under conditions of incarceration than those in the community. Linked with the extraordinary explosion over the last 20 years in the population of Americas jails and prisons and with a disproportionate number of mentally ill inmates, inadequate knowledge currently exists to guide clinical decision-making. Over the last decade, a gradually growing body of work, ethically developed and clinically focused, has been evolving. This article presents the challenges of conducting correctional research in health and healthcare delivery. Legal, ethical, and pragmatic barriers are reviewed. Further, practical solutions that allow meaningful research to be conducted are presented. Such research can create a foundation for developing both public policy and clinical practice.

Early Adolescent Family Experiences and Perceived Social Support in Young Adulthood.

Although the protective role of social support is well established in the health literature, antecedents of perceived social support are not well understood. Research on family experiential factors during early adolescence, an important psychosocial developmental period in the life course, represents a promising line of inquiry. Using a sample of young adults in Miami-Dade County, Florida (N = 1,267) involving longitudinal data spanning 8 years, we evaluated the importance of early adolescent family experiences (socioeconomic status, family structure, family support, family pride, parent derogation) on perceived family and friend support in young adulthood. Results indicated that early family experiences, especially negative experiences, were associated with lower perceived family and friend support in young adulthood. Moreover, these associations were independent of early childhood-adolescent behavioral disorders (attention deficit hyperactivity disorder, conduct), psychological disorders (major depression, anxiety), substance use disorders, and lifetime social adversity. The importance of family experiences during early adolescence for later perceived social support is discussed.

The mental health and psychosocial adjustment of Cuban immigrants in south Florida

Given documented variation in pre-migration and migration-related experiences, Cuban immigrants in the U.S. who arrived during or subsequent to 1980 may be disadvantaged in mental health and psychosocial adjustment relative to earlier arrivals. Using wave 1 of the Physical Challenge and Health study, we compare earlier and later arriving immigrants in levels of depression, anxiety, and self-esteem and test whether adversity and social support, acculturation-related factors, or pre-migration conditions account for any differences observed among a sample of adults living in South Florida (N = 191). Bivariate analyses reveal that later arrivals are relatively disadvantaged in anxiety and self-esteem and marginally so in depression. While later arrivals do not report more adversity in the U.S., they have lower levels of family support to cope with any adversity experienced. Later arrivals are also less likely to interview in English or to have a strong American identity, and they were more likely to have arrived as adults. Relative disadvantages in anxiety and self-esteem are best explained by indicators of acculturation and family support. Policies and programs that address acculturation difficulties and increase family support could improve the health and adjustment of these and similar immigrants.

Medicaid Policies and Practices in US State Prison Systems

Medicaid is an important source of health care coverage for prison-involved populations. From 2011 to 2012, we surveyed state prison system (SPS) policies affecting Medicaid enrollment during incarceration and upon release; 42 of 50 SPSs participated. Upon incarceration, Medicaid benefits were suspended in 9 (21.4%) SPSs and terminated in 28 (66.7%); 27 (64.3%) SPSs screened prisoners for potential Medicaid eligibility. Although many states supported Medicaid enrollment upon release, several did not. We have considered implications for Medicaid expansion.

Robbing Peter to pay Paul: did New York State's outpatient commitment program crowd out voluntary service recipients?

OBJECTIVE This study examined whether New York States assisted outpatient treatment (AOT) program disadvantaged voluntary service recipients by directing services toward court-ordered individuals. METHODS Administrative data from the New York State Office of Mental Health were linked with Medicaid claims from 1999 through 2007 to compare trends in utilization of enhanced outpatient services by involuntary and voluntary service recipients with serious mental illness. Multivariable time series analysis was used to examine the likelihood that voluntary care seekers (N=3,295) either did not initiate or did not receive assertive community treatment or intensive case management during any month as a function of the number of AOT orders in the system. RESULTS New York State appropriated new resources for enhanced community-based mental health services to implement AOT. During the first three years of the AOT program, most of the expansion in enhanced services was directed toward individuals under court-ordered treatment, which appears to have affected voluntary care seekers by lowering their odds of initiating enhanced services and raising their odds of having these services discontinued or no longer receiving them. However, after the first three years of AOT, enhanced service provision expanded steadily among both voluntary and involuntary recipients. CONCLUSIONS In tandem with New Yorks AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients.

SES and race-ethnic differences in the stress-buffering effects of coping resources among young adults

Objectives This study assesses socioeconomic status (SES) and race-ethnic differences in the extent to which coping resources (social support and self-esteem) buffer the negative impact of chronic stress on depressive symptoms. Design We analyze data from a large community-based sample of young adults (ages 18–23) living in Miami-Dade County, Florida, USA (N = 1411). Results Study findings indicate that the stress-buffering effects of social support or self-esteem do not vary by SES. However, independent of SES and other study controls, non-Hispanic whites experience greater stress-buffering effects from social support than African-Americans and African-Americans experience greater stress-buffering effects from self-esteem than Cubans and Nicaraguans. Conclusion In light of these results, we conclude that a greater understanding of racial and ethnic differences in mental health requires close attention to cultural transmissions of coping strategies within groups, which may be partly responsible for these differences in buffering effects.

Evaluating START NOW: A Skills-Based Psychotherapy for Inmates of Correctional Systems

OBJECTIVE This study investigated whether higher attendance in a skills-based group therapy program designed for inmates was associated with fewer rule infractions as reflected in the number of disciplinary reports received in a state correctional system. METHODS Administrative data were provided by the Connecticut Department of Correction and Correctional Managed Health Care at UConn Health, the systems health care organization. This was a retrospective cohort analysis of START NOW program participation events from 2010 through 2013 (N=946). Participants were adult male and female inmates, both sentenced and unsentenced, with and without recorded psychiatric diagnoses. The number of disciplinary reports was documented for up to six months after program participation. Incident rate ratios are presented from zero-inflated negative binomial regression models. Predictive margins examined variation in the effect of sessions attended on disciplinary reports in the postprogram period across security risk groups and primary psychiatric diagnosis groups. RESULTS For each additional session of START NOW completed, a 5% reduction was noted in the incident rate of disciplinary reports. The effect of program participation was robust to all model considerations. Inmates with higher overall security scores appear to benefit most from program participation. The program was also found to be effective across primary psychiatric diagnosis classifications. CONCLUSIONS START NOW was shown to be an effective treatment option for reducing disciplinary infractions by inmates.

Order Out of Disorder: The Vision of Heraclitus

My interest in chaos thcory began as an interest in aesthetic theory. I sought to capture the dynamics of the art experience and found myself faced with questions fundamental to all areas of inquiry. These are questions concerning the creation of meaning. Handling such questions, it became necessary to considcr the perspectives taken whcn creating meaning. I hoped that chaos theory, with its unique perspective, would go some way toward filling the gaps left in our understanding of the art experience by traditional perspectives. The end product of this pursuit was not a direct application of chaos theory to aesthetics but rather an application to theory generally and to that of psychotherapy specifically. Still, it is hoped the reader will consider the arguments made here for their import to aesthetic theory.

Time‐clustered Deaths and Substance Use Disorder among Young Adults

This study assesses whether experiencing multiple deaths of loved ones clustered in time increases risk for substance use problems. Using survey data from a community sample of young adults in Miami, Florida (N = 1747), time-clustered deaths were categorized based on the age of the respondent at the time of each death, with less time between deaths representing greater time-clustering. Results indicate that young adults experiencing multiple deaths that are highly time clustered are at increased risk for substance use disorder and alcohol use. This study provides an alternative way of thinking about how young people may be affected by major life events. It suggests that the increased risk for substance use disorder associated with multiple deaths may be more likely to materialize when the deaths are highly clustered in time.